Exam 2 Tissue Integrity

Granulation

reddish brown forms on surface of wound when it is healing (means body is healthy & wound is healing)

Psoriasis: Treatment systemic treatment

- Methotrexate - cyclosporine - biologics (adalimumab, etanercept, others)

Daptomycin adverse effects

- N/V/D - constipation - headache - insomnia - rash - muscle injury - fever - cough - SOB - resp failure

Carbapenems adverse effects

- N/V/D - super infections - rash - pruitis - seizures

Patients with darker skin pressure sores

SKIN: - purple - brown - blue TEMP: - warm initially - then cooler CONSISTENCY: - boggy - edematous tissue SENSATION: - pain - itchy

Penicillins

- Narrow spectrum - PO,IM,IV - not effective against MRSA infections - Penicillins and aminoglycosides should never be mixed in same IV solution - least toxic of all antibiotics - clinically very safe -metabolized & eliminated by kidneys

Nursing assessment & management

- Nurses critical in prevention and treatment - Assess skin of every patient on admission & every shift - Assess ALL pts for RISK for skin breakdown every 24 hours - Stage III and IV pressure injuries acquired after admission - NEVER want to happen

Vancomycin

- Only active against gram-positive bacteria - Used in treatment of c-difficile, MRSA, and other serious infections, especially active against staph aureus and staph epidermidis - IV administration, eliminated unchanged by the kidneys

Cephalosporins Fifth Generation: Ceftaroline

- Only cephalosporin effective against MRSA - Used for skin and soft tissue infections

Stage 1 pressure injury

- intact skin - NON- blanchable redness - over bony prominence - painful, firm, warmer, or cooler - darkly pigmented skin may not have visible blanching, but color may differ from surrounding area

Pressure injury infections

- leukocytes - fever - increased injury size, odor, drainage - necrotic tissue - indurated - warm - painful

Psoriasis mild

- red patches covered with silvery scales on - scalp - elbows - knees - palms -soles

A patient with diabetes is admitted for an exploratory laparotomy for abdominal pain. When planning interventions to promote wound healing, what is the nurse's highest priority? A. Maintaining the patient's blood glucose within a normal range B. Ensuring the patient has an adequate dietary protein intake C. Giving antipyretics to keep temperature less than 102˚F D. Redressing the surgical incision with a dry, sterile dressing twice daily

A

The nurse is caring for a patient with an infected surgical wound. The patient is being treated with IV Vancomycin. Which of the following are possible adverse effects of this medication? Select all that apply. A. Flushing, rash, pruritis, tachycardia, and hypotension (Red Man Syndrome) B. Renal failure C. Hepatotoxicity D. C-difficile infection E. Neurotoxicity F. Ototoxicity

A B F

Cephalosporins Fourth Generation: Cefepime

Active against pseudomonas and other resistant organisms

A young male patient with paraplegia has a stage II pressure injury and is being cared for at home by his family. To prevent further tissue damage, what instructions are most important for the nurse to teach the patient and family? A. Change the patient's bedding frequently. B. Apply a hydrocolloid dressing over the injury. C. Change the patient's position every 1 to 2 hours. D. Record the size and appearance of the injury weekly

C

What is the best method to prevent the spread of infection to others when the nurse is changing the dressing for a wound infected with Staphylococcus aureus? A. Change the dressing with sterile gloves. B. Apply antibiotic ointment over the wound. C. Wash hands and properly dispose of soiled dressings. D. Soak the dressing in sterile normal saline before removal

C

The nurse could delegate care of which patient to a licensed vocational nurse (LVN)? A. The patient who reports increased tenderness and swelling around a leg wound. B. The patient who was just admitted after suturing of a full-thickness arm wound. C. The patient who needs teaching about home care for a draining abdominal wound. D. The patient who requires a dressing change for a stage III pressure injury.

D

Pressure injury prevention

Keep skin dry - if incontinent clean with no-rinse perineal cleaner & apply barrier ointment Reposition - drawsheet or transfer board - position patient at 30-degree lateral position - HOB at 30 degree or less - trapeze bar Turning schedule Nutrition & fluid intake - consult dietician

Pressure injury recurrence

tissue breakdown/repeat pressure injuries

Psoriasis

§Chronic autoimmune inflammatory disorder characterized by plaque formation with varying degrees of severity

A patient who has severe psoriasis on the face, neck, and extremities is socially withdrawn because of the appearance of the lesions. Which action should the nurse take first? A. Discuss the possibility of participating in an online support group. B. Encourage the patient to volunteer to work on community projects. C. Suggest that the patient use cosmetics to cover the psoriatic lesions. D. Ask the patient to describe the impact of psoriasis on quality of life.

D

A patient with rheumatoid arthritis has been taking oral corticosteroids for two years. Which nursing action is most likely to detect early signs of infection in this patient? A.Monitor white blood cell counts. B.Check the skin for areas of redness. C.Measure the temperature every two hours. D.Ask about feelings of fatigue or malaise.

D

Linezolid

- Oxazolidinone antibiotic (new) - Effective against multi-drug resistant gram-positive pathogens, including MRSA, but should be reserved for specific infections to prevent development of resistance

Clindamycin

- Used as alternative to penicillin - drug of choice for severe group A streptococcal infections and gas gangrene, covers most anaerobic bacteria (+/-) and most gram positive anerobes - May be administered orally, IM, or IV - Undergoes hepatic metabolism, excreted by urine and bile

Fluoroquinolones

- Variety of infections, including skin infections - Metabolized by liver, excreted in urine

Psoriasis two processes

- accelerated maturation of epidermal cells - excessive activity of inflammatory cells

Risk factors of pressure injuries

- Advanced age - Anemia - Contractures - Diabetes - Elevated body temperature - Friction - Immobility - Impaired circulation - Incontinence - Low diastolic BP (<60 mmHg) - Mental deterioration - Neurologic disorders - Obesity - Pain - Prolonged surgery - Vascular disease

Antibiotic Resistance

- Bacteria acquire resistance through conjugation - Antibiotics promote emergence of drug-resistant organisms by creating selection pressures that favor them

Cephalosporins

- Bactericidal, beta-lactam antibiotics, similar to penicillin structure

Carbapenems

- Beta-lactam antibiotics - IV administration - Very broad-spectrum - not effective against MRSA - Effective for treating mixed infections - intra-abdominal infections, and complicated skin and soft tissue infections - Elimination primarily renal

Treatment of Skin and wound Infections

- Cephalosporins §- Some penicillins (narrow-spectrum pcn) - Carbapenems - Vancomycin - Clindamycin - Linezolid - Daptomycin - Levofloxacin

Psoriasis: Treatment Phototherapy

- Coal Tar plus Ultraviolet B Irradiation - Affected area covered with 1% coal tar ointment for 8-10 hrs, washed off, area then exposed to UVB light - Expensive and time-consuming treatment, very safe, remission in 80% of patients, up to 30 treatments necessary

Psoriasis: Treatment phototherapy

- Coal tar plus UVB irradiation - photochemotherapy (PUVA therapy)

Daptomycin

- Cyclic lipopeptide (new) - Can kill all clinically-relevant gram-positive bacteria, including MRSA - Approved for use with bloodstream infections and complicated skin and soft tissue infections - Administered IV

Venous leg ulcer risks

- DVT - diabetes - obese - pregnant

Lower Extremity injuries

- Different pathophysiology from pressure injuries - In general, related to changes in blood flow to lower extremities due to chronic disease processes

Venous Leg ulcer

- Found in lower legs, have irregular wound margins and superficial, ruddy granular tissue - Painless to moderately painful - Surrounding skin may be scaly, weepy, dry and thin - Compression therapy promotes blood return and prevents blood from pooling

Unstageable pressure injury

- Full-thickness tissue loss in which actual depth or injury is completely obscured by slough or eschar in wound bed - Slough or eschar must be removed to expose the base of the wound in order to stage - Note: Stable, dry eschar on heels should not be removed

Psoriasis: Treatment systemic treatment Methotrexate Adverse Effects

- GI upset - blood dycrasias - bone marrow suppression - must monitor hepatic function - pregnancy must be avoided

Psoriasis: Treatment topical treatment

- Glucocorticoids - vitamin D3 analogs - tazarotene - salicylic acid - anthralin - tars

Diabetic injuries

- Located on plantar aspect of foot, over metatarsal heads, under heels and on toes (bony prominences) - Painless, even wound margins, rounded or oblong shape with surrounding callous - Can easily turn into cellulitis or osteomyelitis - Treatment includes removing stress/pressure from injured site, debriding wound, antibiotics if infection occurs

Cephalosporins Adverse Effects

- Maculopapular rash - Should not be given to patients with a history of severe reaction to penicillins (potential for fatal anaphylaxis), may be used in patients with mild penicillin allergy - Can cause bleeding tendencies due to interference with vitamin K metabolism - Thrombophlebitis - Hemolytic anemia (very rare)

Psoriasis: Treatment Photochemotherapy

- Orally-administered photosensitive drug combined with UVA light therapy - Alters DNA structure, decreases proliferation of epidermal cells - Adverse effects: pruritus, nausea, erythema - May also accelerate aging of skin and increase risk of skin cancer - Indicated for extensive, active psoriasis

Psoriasis: Treatment systemic treatment Biologic agents

- adalimumab - etanercept - given subQ or IV - Most block tumor necrosis factor (TNF) - Suppress immune function, leading to decreased inflammation in psoriasis - Very effective, first line for severe psoriasis - Potential for serious opportunistic infections due to immunosuppressant activity

Penicillin adverse effects

- allergies - pain at IM injection site - neurotoxicity

Clindamycin adverse effects

- c-diff - abd pain - fever - leukocytosis - hepatotoxicity

Psoriasis: Treatment topical treatment Vitamin D3 Analogs

- calcipotriene - calcitriol - Inhibit proliferation of keratinocytes - Adverse effects mild, may include itching, irritation, and erythema

Psoriasis: Treatment systemic treatment Methotrexate

- cytotoxic agent, given PO, IM, or IV - Helps with psoriasis by reducing proliferation of epidermal cells - Highly toxic, should be used only in patients with severe, debilitating psoriasis that has not responded to other therapy

Cellulitis patho

- deep inflammation of sub-Q tissue caused by enzymes produced by bacteria

Clinical manifestations tissue injuries

- depends of extent of tissue involved - staged/categorized based on visible or palpable tissue in the injury bed - staging is based on the National Pressure injury Advisory Panel (NPUAP) - Stage 1 (minor) to stage 4 (major) - presence of slough or eschar may prevent staging until it is removed

Wound care specialists pressure injury

- determines cleansing protocol - appropriate dressings - clean with normal saline or water to avoid damaging cells - keep slightly moist to encourage re-epithelialization

Red man syndrom

- flushing - rash - pruritus - urticaria - tachycardia - hypotension - due to rapid infusion

Arterial Ulcer

- found between toes or on tips of toes, areas with rubbing footwear - even wound margins, punched out appearance, pale , deep wound bed - extremely painful - minimal exudate - Must revascularize with stents to treat ischemia, then topical treatments will help with healing injury - shiny, dry, no hair

Stage 4 pressure injuries

- full-thickness loss, extends to muscle, bone, supporting structure - bone, tendon, or muscle may be visible or palpable - slough or eschar may be present on some parts of the wound bed - undermining & tunneling may also occur

Stage 3 pressure injury

- full-thickness skin loss - sub-Q tissue may be visible, but bone, tendon, or muscles - presents as deep crater with possible undermining or adjacent tissue - injury depth varies by location, depending on depth of tissue in that area

Penicillin avoid intra-arterial injection

- gangrene - necrosis - sloughing of tissue can result

Cellulitis clinical manifestations

- hont - tender - erythematous - edematous area with diffuse borders - chills - malaise - fever

Pressure injuries

- localized injury to skin & underlying tissue - bony promises - most common of sacrum & heels - results from pressure or shearing forces - injury or medical related - heal by secondary intention

Surgical treatment for pressure injuries

- may be necessary - skin graft - skin flaps - musculocutaneous flaps

Psoriasis severe

- may involve entire skin surface & mucous membranes - superficial pustules - high fever - leukocytosis - painful fissuring of the skin

Cellulitis treatment

- moist heat - immobilization - elevation - systemic antibiotic therapy - possible hospitalization - progression to gangrene if left untreated

Other Skin Damage

- moisture associated skin damage (MASD) - medical adhesive related skin injury (MARSI) - skin tears

Psoriasis: Treatment topical treatment Glucocorticoids

- most commonly used, suppress inflammatory cells - High-potency agents should NOT be used on face, groin, axilla, or genitalia

Stage 2 pressure injury

- partial thickness loss of dermis - shallow opening - red/pink wound bed - intact or ruptured serum-fill blister - shiny or dry shallow injury without slough or bruising - adipose (fat) is NOT visible, & deeper tissue are NOT visible - granulation tissue, slough & eschar are NOT present

Influencing factors with pressure injuries

- pressure intensity - pressure duration - tissue tolerance - shearing forces - moisture

Care planning pressure injury

- prevent deterioration of injury - reduce factors that contribute to pressure & skin breakdown - prevent infection - promote healing - prevent recurrence

Prevention of resistance

- preventing infection - diagnosing & treating infection effectively - using antimicrobial drugs wisely - prevent-to-patient transmission of infections

Cephalosporins Drug interactions

- probenecid - alcohol - anticoagulants - calcium & ceftriaxone (rocephin)

Suspected deep tissue injury

- purple/maroon localized area of discolored intact skin of blood filled blister - indicated damage of underlying soft tissue from pressure/shear - tissue that is painful, firm, mushy, boggy, warmer, or cooler as compared to adjacent tissue - may be difficult to detect in patients with dark skin tones

Psoriasis: Treatment goal

- reduce inflammation - suppress rapid turnover of epidermal calls

Vancomycin adverse effects

- renal failure - ototoxicity (rare, reversible) - red man syndrom - thrombophlebitis is common - thrombocytopenia (rare) - admin 60 mins

Pressure injury documentation

- stage - size - location - educate - infection - pain - tissue appearance - maybe a picture

What are the most common bacterias that cause cellulitis?

- staph - strep

Psoriasis: Treatment topical treatment Tars

- suppress DNA synthesis, mitotic activity, and cell proliferation - Coal tar is used most often, may be found in shampoos, lotions, creams - Unpleasant odor, can cause irritation, stinging, burning - Can stain skin and hair

Cephalosporins Third Generation: Ceftriaxone

- surgical prophylaxis - bone and joint infections - skin and soft tissue infections

Eschar

- tan - brown - black (dry dead tissue on surface of skin)

Patient & family teaching pressure injuries

- teach prevention techniques to patient & caregivers, including early signs of skin breakdown & tissue injury - continued nutritional support - pressure injury care techniques, wound care at home

Fluoroquinolones adverse effects

- tendon rupture -N/V - headache - muscle weakness - phototoxicity

Slough

- yellow - tan - green - brown (moist)

Linezolid adverse effects

-N/V/D - headache - dizziness Should not be used with SSRIs, ephedrine, pseudoephedrine, cocaine

Pressure injury if not treated

-cellulitis - sepsis - death

Carbapenems interactions with valprote

Imipenem reduces blood levels of valproate, can lead to breakthrough seizures